- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,906.00 / $4,235.59 / $7,119.04
| Facility | | $2,906.00 | $4,235.59 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.50 / $883.92 / $2,387.38
| Professional | | $562.50 | $883.92 | $2,387.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.48 / $1,544.43 / $11,139.12
| Facility | | $930.48 | $1,544.43 | $11,139.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.73 / $1,552.91 / $6,616.19
| Facility | | $1,092.73 | $1,552.91 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,217.00 / $5,327.00 / $8,342.00
| Facility | | $4,217.00 | $5,327.00 | $8,342.00 |